A nurse is caring for a client who gave birth 2 hr ago.
The nurse notes that the client's blood pressure is 60/50 mm Hg. Which of the following actions should the nurse take first?.

Evaluate the firmness of the uterus (fundus).

Obtain a type and crossmatch.

Administer oxytocin infusion.

Initiate oxygen therapy by nonrebreather mask.

Answer and Explanation

The Correct Answer is A

The correct answer is choice A.

Choice A rationale:

Evaluating the firmness of the uterus (fundus) is the first action the nurse should take when a client’s blood pressure drops postpartum. A soft or “boggy” uterus can indicate uterine atony, a leading cause of postpartum hemorrhage, which can lead to hypotension.

Choice B rationale:

Obtaining a type and crossmatch is important if the client needs a blood transfusion, but it is not the first action the nurse should take.

Choice C rationale:

Administering oxytocin infusion can help contract the uterus and control bleeding, but the nurse should first assess the uterus.

Choice D rationale:

Initiating oxygen therapy can help if the client is hypoxic, but the nurse should first assess the uterus.

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Correct Answer is D

Explanation

The correct answer is choice D. At the level of the umbilicus.

Choice A rationale:

The uterine fundus is not typically found to the right of the umbilicus after delivery.

Choice B rationale:

The uterine fundus is not typically found 2 cm above the umbilicus after delivery.

Choice C rationale:

The uterine fundus is not typically found one fingerbreadth above the symphysis pubis after delivery.

Choice D rationale:

After delivery, the uterine fundus is typically found at the level of the umbilicus.

A. Variable decelerations. B. Early decelerations. C. Accelerations. D. Late decelerations.

Correct Answer is A

Explanation

The correct answer is choice A.

Choice A rationale:

Variable decelerations are associated with problems with the umbilical cord, such as compression. This is because they occur irregularly and can happen at any time during the contraction cycle.

Choice B rationale:

Early decelerations are usually benign and are associated with fetal head compression during a uterine contraction. They are not typically indicative of a problem with the umbilical cord.

Choice C rationale:

Accelerations are usually a sign of fetal well-being and are not typically associated with umbilical cord issues.

Choice D rationale:

Late decelerations are associated with uteroplacental insufficiency, which is a decrease in the blood flow to the placenta that reduces the amount of oxygen and nutrients transferred to the fetus. They are not typically indicative of a problem with the umbilical cord.

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A nurse is caring for a client who gave birth 2 hr ago.The nurse notes that the client's blood pressure is 60/50 mm Hg. Which of the following actions should the nurse take first?.

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Naxlex Comprehensive Predictor Exams

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A nurse is caring for a client who gave birth 2 hr ago.
The nurse notes that the client's blood pressure is 60/50 mm Hg. Which of the following actions should the nurse take first?.